clinical case study: acute onset heart failure
DESCRIPTION
Clinical Case Study: Acute Onset Heart Failure. Amy Lofley Case study #2. Objectives. Overview of Acute Heart Failure Physiology Pathophysiology Treatment Multidisciplinary team. Case Study Medical Hx Nutrition Assessment Nutrition Intervention Prognosis Conclusion. - PowerPoint PPT PresentationTRANSCRIPT
AMY LOFLEYCASE STUDY #2
Clinical Case Study: Acute Onset Heart Failure
Objectives
Overview of Acute Heart Failure Physiology Pathophysiology Treatment
Multidisciplinary team
Case Study Medical Hx Nutrition Assessment Nutrition Intervention Prognosis Conclusion
CLINICAL UPDATE
Acute Heart Failure
Normal Physiology
The heart pumps blood throughout the body to deliver oxygen and nutrients and bring back carbon dioxide and waste.
A normal heart is able to pump this blood effectively throughout the body.
http://filer.case.edu/dck3/heart/intro.html
Pathophysiology (1)
In heart failure the heart isn’t able to pump adequate blood supply to the rest of the body. This is indicated by a low ejection fraction and a high
B-natriuretic peptide (BNP). It does not mean that an individual has had a
heart attack or that the heart is no longer working.
The beginning stages of HF are usually asymptomatic and can progress if not treated.
http://www.annerporterco.com/is-your-heart-failure-systolic-diastolic-or-both.html
Pathophysiology
http://www.annerporterco.com/is-your-heart-failure-systolic-diastolic-or-both.html
Stages of Heart Failure (2)
Classification of Heart Failure (1)
Class I – No undue symptoms associated with ordinary activity and no limitation of physical activity
Class II – Slight limitation of physical activity; patient comfortable at rest
Class III – Marked limitation of physical activity; patient comfortable at rest
Class IV – inability to carry out physical activity without discomfort; symptoms of cardiac insufficiency or chest pain at rest
Risk Factors
HypertensionDMCoronary Heart DiseaseLeft ventricular hypertrophy AgeDyslipidemia \ObesityAtherosclerosis
Practice Recommendations
Primary treatment Treated with IV lasix
Primary intervention MNT
Fluid restriction 1500 mg Na restriction
Evidence-Based Practice (3)
Referral to a RD for MNT when an individual has HF. An initial visit lasting 45 minutes and up to three planned follow up visits lasting 30 minutes to improve diet and quality of life.
Protein needs for patients are based on their nutrition status. Patients that are clinically stable but protein depleted should have at least 1.37 g/kg and patients with a normal nutrition status should have 1.12 g/kg actual body to preserve body composition and limit hypercatabolism.
Evidence-Based Practice (3)
Energy needs are best determined with indirect calorimetry but if not possible usual predictive equations should be used adjusting with increased needs for a catabolic state.
Fluid should be limited to between 1.4 and 1.9 L per day, depending on symptoms of edema, fatigue, and shortness of breath.
Sodium intake should be limited to less than 2000 mg per day from AND and 1500 mg from the AHA.
Patients with HF should consume the DRI for folate, B6, and B12.
A multi-vitamin/mineral should be recommended that contains B12, B6 and folate.
Evidence-Based Practice (3)
Thiamine status should be monitored closely because of diuretic use. Encouraging the patient to consume the DRI of thiamine is important until further research is conducted.
Magnesium should be consumed at the DRI because of the increased risk for HF patients to have an irregular heart beat.
Multidisciplinary team
Physician Hospitalist Cardiologist
Registered Dietitian Nurses
PCT RN HF RN
Case Study
Mr. F
Age: YOM, Caucasian Presents to hospital with shortness of breath, weakness, and
chest pain
Medical Diagnosis Acute episode of heart failure UTI
Past Medical/Surgical/social History
Past Medical History Stage 4 CKD HTN UTI Hypothyroidism CHF Severe mitral
regurgitation Non-ST elevation
myocardial infarction with possible (A1)
Paroxysmal atrial fibrilation
Past Surgical History No significant hx
Social History Lives with wife at
home
Clinical Data
Physical Exam Appears to be at a
normal weight Resting comfortably in
the bed Stage 2 decubitus
ulcer on bottom Heels red Decreased appetite
Nutrition Assessment Height: 64 inches Weight: 68.9 kg No wt changes pta BMI: 26.07
Labs/Medications
Lab Lab Value Normal ValueAlbumin 2.6 3.5-5
Creatinine 1.7 .6-1.2 mg/dL
FSBS 94-106
Medications: lasix
Dietary data
According to patient, he follows a no added salt diet at home.
Nutrition Assessment
Calorie Needs 25-29 kcals/kg/d 1725-2000 kcals
neededFluid Needs
2000 mL Fluid Restriction
Protein Needs 1-1.2 g/kg/d 69-80 g needed
Nutrition diagnosis
Increased nutrient needs (protein/kcals) RT increased demands for wound healing AEB skin breakdown, delayed wound healing, decreased intake x 2 days.
Food and nutrition related knowledge deficit RT lack of prior diet education AEB lacks understanding of prescribed diet
Nutrition Intervention
PO intake at least 50% in 5 days.50% intake of supplement next 5 days.
Add berry magic cup BID and pb grahams BIDMaintain wt within 1 kg of 68.9 kg over next 5
days.Prevent further skin breakdown and help heal
decubitus ulcers next 5 days.Pt will identify high fat/chol/sodium foods
within the next 5 days.HF nutrition education to caregiver. Good
comprehension and expect good compliance
Nutrition Monitoring and Evaluation
Monitor and evaluate: GI tolerance Labs PO intake Skin integrity and wound healing Weight Monitor 2 times weekly
Follow Up Assessment
Diet order: 1500 mg Na, 2000 FR
New PES: Inadequate oral intake RT decreased appetite AEB <50% PO intake.
PO intake 50-75%, < 240 ml fluid per meal
Assessment Wt. 54.9 kg No change in skin
noted
Tolerating food with no complaints
Labs Alb 2.6, Cr 1.9, FSBS
93-124Hospice is being
consultedGoal: Intake to meet
> 50% of needs next 3-4 days ( met and continue)
Monitor GI, labs, PO adequacy, skin and wt
Expected Outcomes
Prognosis is goodA full recovery from Acute episode of HF
should occur within the next week Wound healing will take time.
References
1. Mahan LK, Escott-Stump S. Medical nutrition therapy for heart failure and transplant. Krause. 2008: 884-897.
2. Jessup M, Abraham WT, Case DE, et al. 2009 focused update: ACCF/AHA guidelins for the diagnosis and management of heart failure in adults. Journal of the American College of Cardiology. 2009; 53(15):1343-82.
3. Academy of Nutrition and Dietetics. Evidence Analysis Library. Available at: http://andevidencelibrary.com/topic.cfm?cat=2800